NURSES’ PERCEPTIONS OF THEIR
CLINICAL LEARNING EXPERIENCES
IN A CORPORATE WORKPLACE
CONTEXT
by
MARIETTE VOLSCHENK
(SU Student number: 14453851)
submitted in partial fulfilment of the requirements
for the degree of
MASTER OF PHILOSOPHY
in
HEALTH SCIENCES EDUCATION
at
STELLENBOSCH UNIVERSITY
SEPTEMBER 2009
DECLARATION:
I, the undersigned, hereby declare that the work contained in this assignment is my original work and that I have not previously submitted it, in its entirety or in part, at any university for a degree.
Signed: _________________ _________________ (M. Volschenk) (Date)
ACKNOWLEDGEMENTS
I wish to express my sincere appreciation and thanks to the following persons and institutions:
• Professor Ben van Heerden, my supervisor and mentor, for his continued guidance, inspiration and support
• The students who agreed to participate in the study, for their valuable contributions
• Panorama Medi-Clinic management, for permission to conduct the study at this hospital
• Ms Martie van Heusden, for assisting with the translation of the interview questionnaire and informed consent forms
• Ms Marianne Dednam, for transcribing the interviews • Ms Janet Bradbury, for proof reading the manuscript
• Special thanks to my mom, Hester, for her support, prayers and understanding throughout my studies
TITLE:
ALL IN A DAY’S WORK: STUDENT NURSES’ PERCEPTIONS
OF THEIR CLINICAL LEARNING EXPERIENCES IN A
CORPORATE WORKPLACE CONTEXT
Authors:
1. Mariette Volschenk (RN, RM, Dipl.Nurs.Ed.) Clinical training facilitator, Panorama Medi-Clinic 2. Ben van Heerden (MB,ChB, MSc, MMed)
Director: Centre for Health Sciences Education, Stellenbosch University
Correspondence address:
Ms M. Volschenk
Training and Development Department Panorama Medi-Clinic P. O. Box 15041 Panorama 7506 Cape Town South Africa Tel: +27 21 938 2298 E-mail: mariette.volschenk@mediclinic.co.za
Contact information of co-author:
Prof. B.B. van Heerden
Centre for Health Sciences Education Faculty of Health Sciences
Stellenbosch University PO Box 19063 Tygerberg 7505 Cape Town South Africa Tel: +27 21 938 9054 E-mail: bbvh@sun.ac.za
The undersigned authors transfer to Nurse Education Today all copyright of which he/she is the owner in respect of the manuscript entitled “ALL IN A DAYS WORK: STUDENT NURSES’ PERCEPTIONS OF THEIR CLINICAL LEARNING EXPERIENCES IN A CORPORATE WORKPLACE CONTEXT”, in the event that the work is published. In the
event that the copyright subsists in someone other than the author, he/she warrants that copyright in the manuscript may be so transferred. The undersigned authors warrant that the article is original, is not under consideration by another journal, and has not been previously published.
Signed:
_________________ _________________
(M. Volschenk) (Date)
_________________ _________________
ABSTRACT
Introduction: Exposure to the clinical learning environment forms an essential part
of nursing education. Individual student perceptions of this multi-dimensional context can greatly influence their clinical learning experiences. Insight into these perceptions may assist nurse educators in facilitating optimal learning outcomes.
Aim: The aim of this study was to promote an awareness of the possible impact of
various aspects of the clinical learning environment and nursing students’ perceptions thereof, on their learning experiences; and to generate guidelines for facilitating optimal learning outcomes.
Methods: A qualitative, interpretive study, investigating nine individual second-year
nursing students, was undertaken in a private hospital in South Africa. Interview transcripts were thematically analyzed.
Results: Four themes and eleven sub-themes emerged, highlighting the impact of
student nurses’ perceptions of the various aspects of the clinical learning environment on their learning experiences.
Discussion: The impact of students’ perceptions of the clinical learning environment on
their learning experiences is discussed. Recommendations are provided for measures to increase the focus on student-centered learning in the selected clinical context.
Conclusion: The challenge remains to best prepare students for the complexities and
dynamics of the workplace learning environment, while at the same time modifying this environment to effectively meet students’ learning needs.
___________________________________________________________________
Key words: clinical learning environment, workplace context, private sector, student perceptions
ALL IN A DAY’S WORK: STUDENT NURSES’ PERCEPTIONS OF
THEIR CLINICAL LEARNING EXPERIENCES IN A CORPORATE
WORKPLACE CONTEXT
INTRODUCTION
Exposure to the clinical learning environment provides nursing students with a unique context for experiential learning and the acquisition of skills that cannot be readily acquired elsewhere. However, although often described as the single most important resource in the development of knowledgeable and competent nursing professionals, it remains essential to take cognisance of the various factors operating in this multi-dimensional workplace context, and the impact of these on student learning (Ousey, 2000; Quinn & Hughes, 2007).
Our study addresses two of the major factors in the clinical arena; namely students’ perceptions of their learning environment and the powerful influence of unintended learning experiences in the workplace context.
BACKGROUND AND LITERATURE REVIEW
Nursing students spend a great deal of their training in the clinical learning environment. It is here that the curriculum provides for opportunities to develop clinical skills, integrate theory and practice, apply problem-solving skills, develop interpersonal skills and become socialized into the formal and informal norms and expectations of the profession (Mellish, et al., 1998; Quinn & Hughes, 2007). Not only do these students have to manage their learning tasks within the social context of the workplace, they also need to face the demands of the workplace environment, where they are required to accept responsibility for patient care according to their scope of practice.
Nursing education within the private sector holds unique challenges in terms of facilitating centered learning. Instead of having an academic, student-centered approach, the focus in this type of organization often emphasises client satisfaction, profitability and the maintenance of a competitive edge. The private health care sector further faces global modern day health care challenges,
2
including staff shortages, increased demands for quality care and greater frequency of litigation against hospitals and individuals.
Contemporary educational literature emphasises the importance of the context and environment in which student learning takes place in order to facilitate optimal learning outcomes (Merriam & Caffarella, 1999; Prosser & Trigwell, 1999; Norman, et al., 2002; Ramsden, 2003; Konings, et al., 2005). Entwistle (1991), however, argues that rather than the learning environment itself, it is often students’ perceptions of a given learning environment that will ultimately determine its impact on the quality of their learning outcomes. This argument highlights the notion of the so-called ‘hidden’ curriculum. Defined as “the set of
influences that functions at the level of organisational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals, and taken for granted aspects”, the hidden curriculum points to the
unintended learning that occurs in a specific context (Lempp & Seale, 2004, p. 770).
Although the hidden curriculum has emerged as an influential concept in medical education, very little attention has been paid to this concept in nursing education literature. However, various studies focus on the clinical learning experiences of nursing students, emphasising the need for a supportive clinical learning environment (Oermann & Garvin, 2002; Midgley, 2006; Levett-Jones & Lathlean, 2009). Factors described that may potentially influence nursing students’ clinical learning experiences include staffing levels, staff attitudes, staff following routine and ritual practices, little time for reflection, time constraints, clinical supervision and mentoring (Wilson, 1994; Dunn & Hansford, 1997; Lee & French, 1997; Chan, 2002). It seems logical that, in the multi-dimensional workplace context, unintended messages may be sent to students, whose perceptions and interpretations thereof may influence their learning experiences in either positive or negative ways.
AIM
The aim of this study was to promote an awareness of the possible impact of various aspects of the clinical learning environment and students’ perceptions thereof, on their learning experiences; and to generate guidelines for facilitating
optimal learning experiences for students at a private healthcare nursing training institution.
METHOD Context
The study was conducted as part of the fulfilment of the requirements for a Masters degree in Health Sciences Education (MPhil in HSE) at Stellenbosch University, South Africa. It was performed in a large, 424-bedded private hospital in South Africa, which forms part of an international corporate health care company.
Design
A qualitative, interpretive study, investigating nine individual second-year undergraduate nursing students, was undertaken in an attempt to gain a deep, interpretive and holistic understanding of the perceptions of these students with regard to their clinical learning experiences in a corporate workplace environment.
Sample
The target population was defined as all sixty second-year nursing students enrolled for the Programme of Pupil Enrolled Nurse at the Western Cape Learning Centre of the Private Hospital Group. In order to ensure a sampling strategy supportive of the purpose of this study, a cross-sectional sample of nine second-year nursing students was selected by means of purposeful sampling. The sample constituted the total second-year nursing student population at the private hospital where the study was conducted, and was thus regarded as representative of the total population in the selected context.
Ethical considerations
Ethical approval was obtained from relevant ethical committees prior to conducting the study. Participation was voluntary and informed consent was obtained in writing from each participant prior to interviews. Audio recordings were deleted after transcripts had been made and verified. All necessary measures were taken to
4
ensure the removal of identifying information as soon as it was no longer necessary.
Students were allowed to speak in the language in which they were most comfortable. No interpreter was required. Afrikaans quotes used for the purpose of this article were translated verbatim into English and are indicated as such.
Data collection
Individual semi-structured interviews were conducted in a private setting within the selected hospital, during students’ clinical rotations. The same guiding questions were asked in each interview, and interesting answers were further explored or clarified. Data saturation was made possible by the broad range of qualitative data provided by participants.
Data analysis
Interviews were transcribed and verified. Member checking did not result in any changes to transcripts. Thematic analysis of interview transcripts was undertaken, supported by the utilization of computer-aided qualitative data analysis software in the form of Atlas.ti.
RESULTS
The qualitative data analysis provided insight into students’ perceptions and interpretations of their clinical learning experiences, as impacted upon by various facets of the clinical learning environment. Four themes and eleven sub-themes emerged as listed in Table 1 (Appendix A). These are discussed below:
Theme 1: Fantasy meets reality
This theme demonstrates how some students’ preconceptions of nursing contributed to differences in their expectations of being a nurse and their actual experiences as students.
Sub-theme 1: The root of it all
Some students had family members who were nurses, while others were exposed to nursing during childhood hospitalization. These students were
inspired to become nurse practitioners themselves and seemed to have fairly accurate perceptions of what nursing would be like.
Sub-theme 2: In the eye of the beholder
A preconception shared by all nine students was that of nursing as a caring and helping profession:
...the nursing profession is about helping people...it’s a very special profession...
(Student 3, translated)
Each of the students indicated that this expectation was met in reality, and they all perceived themselves as even more caring since they started nursing.
A few students related to popular media representations and experienced disappointment when their expectations were not met in reality:
I used to watch Grey’s Anatomy, and I knew it wouldn’t always be like that, but you have this nice picture of what it can be like...I always thought doctors and nurses, we will be like one great team…that everything will just go well all the time, but it did not work out like that... (Student 4, translated)
... it was not at all what I expected, because you don’t think that you would have to wash people and turn them, and do everything for them....You grow up very quickly. (Student 6, translated)
Stereotyping may also influence patient attitudes towards nursing students. Student responses indicated that some patients viewed nursing as a female profession and preferred to receive nursing care from female nurses only.
... People usually expect to see a female nurse, and then it’s not easy for them to accept being cared for by a male nurse...especially in the case of female patients
(Student 3, translated).
The stereotyping of nurses as humble and submissive females had some resultant unpleasant experiences where doctors were rude to students, or where male patients made inappropriate remarks towards young female students.
6
Theme 2: The work of learning
This theme demonstrates the impact of work-place dynamics on student learning. Although a greater sense of self-confidence and cohesion with ward staff emerged in their second year, students reported feeling anxious and unappreciated when first entering the wards.
Sub-theme 1: Sink or swim
A few students reported incidents where negative staff attitudes left them struggling on their own with difficult or unfamiliar tasks or procedures. Some students felt that it was too much trouble for ward staff to help them, while others perceived the ward staff’s unwillingness to help as reluctance to perform procedures according to the book:
...when people have been working in a ward for a long time, they have fallen into
such a rut…everything is too much trouble… (Student 9, translated)
They don’t really want to be with us students, because they take it, like, then they have to do it the way we must do it... (Student 5, translated)
Student 8 indicated that staff attitudes caused her to feel abused in a ward where she was placed during her first year:
...in that ward, at night, if you are...a student you must know if you’ve got eight
patients...you must do the full-washes alone, you gonna make those beds alone...while, when the staff nurses are finished quarter to six…they just wash hands and sit at the nurses’ station.
Student 4’s account demonstrates the disappointment students experienced when due recognition was not given:
The baby’s heart rate stayed 250 the whole time...I was so proud of myself
because I detected it, and it’s not as if I wanted everyone to go, like, ‘you are so wonderful’; but no-one even said ‘wow, that was good, you showed good insight’... (Translated)
Students indicated that certain behaviours were useful in helping them to become accepted as part of the ward team. These included being humble,
useful, hard-working, respectful, and not questioning ward staff:
...you need to do a lot from your side, but...if you pull your weight, then they are better towards the student, they accept you more and help you more... (Student
7, translated)
Sub-theme 2: Helping hands
This theme articulates the impact of staff shortages on student learning. Students’ responses indicate that they sometimes felt more like a pair of hands than a student. Apart from being counted as part of the work force, which meant that they also had to help out in other wards experiencing staff shortages, students were often left to their own devices, and were given a hard time when they requested permission to leave their placement wards to go and do procedure assessments.
Sometimes you’re sent out as well, and then you don’t get the chance to complete your procedures in a specific ward... (Student 9, translated)
Everyone is running around. You take a lot longer...you just hope you are doing
it correctly... (Student 6, translated)
Sometimes when we have to do procedures, you really struggle to get out of the ward, and the people make you feel so bad, that in the end you don’t want to ask to be excused... (Student 5, translated)
Sub-theme 3: In the line of duty
Much of the interview data emphasised the importance of relationships in socializing nursing students into the cultures of both the organization and the nursing profession. Students’ responses further articulated their awareness of the hierarchical system existing in the wards. Many of the students indicated that they were told about what nursing was like in the ‘old days’ by more mature nursing staff. These ‘messages from the past’ seemed to strengthen students’ awareness of their own place in the hierarchical system, as demonstrated by Student 6’s remark:
8
like the first-years, they don’t really respect us; I don’t know what’s going on with them. (Translated)
Theme 3: The learning game
This theme demonstrates how teaching-learning dynamics operating in the clinical environment may promote discrepancies between the intended and the experienced curriculum, including theory-practice discrepancies and ineffective feedback methods. On a positive note, student responses pointed towards an assessment system that drives learning.
Sub-theme 1: When in Rome …
Student 4’s response highlighted the discrepancies experienced by many students between what was taught in class and what happened in practice:
...we were taught four-hourly catheter care, but it does not always work like that;
and the school places... a lot of pressure on you to do it like that... (Translated)
Students’ perceptions were that ward staff often took the shorter route to save time; and at times some students even seemed to question the logic of what was taught in class when faced with the realities of staff shortages:
...sometimes it bothers me, because it doesn’t feel right, but other times I sort of
agree with them when they do it in the shortened version... (Student 2,
translated)
Sub-theme 2: Feedback, backwards
Student responses indicate that feedback in the wards was mostly delivered as a student report form at the end of placements, instead of verbally and on a continuous basis. No mention was made of reflection activities in the wards:
... this is one of the biggest problems, because you go about in the ward and you are under this false impression that you’re doing things right all the time, but in the mean time no one wants to tell you that you’re actually doing it incorrectly... you want to know where you made your mistakes. This is the whole point of learning, you want to improve... (Student 4, translated)
Student 5’s response reflects her perception that student reports were sometimes used as a power game to subtly enforce conforming behaviour:
... you cannot disagree with them, because then you are, like, rude and at the end of the day they feel they have the whip hand and they are going to write your report...and they did not write a good report about me... (Translated)
Student 7 perceived feedback as somewhat inaccurate and unfair at times:
...It makes me really angry, because how do you write a report about someone if you’ve not even once stood by and checked how they work? (Translated)
Sub-theme 3: Assessment opens doors
All students indicated that they viewed assessment in a positive light, because it expanded their scope of practice and increased their levels of self-confidence. On the other hand, they perceived themselves now as more ‘useful’ to ward staff: It feels great if you... pass...and now you can apply it. You feel like you actually
mean more. (Student 5, translated)
Theme 4: The values of the Profession
This theme focuses on value clarification, role modelling, and quality control.
Sub-theme 1: To do or not to do, that is the question...
None of the students interviewed had, at this stage, been confronted with anything that severely compromised their personal values. However, Student 1 indicated uncertainty as to how she would handle such challenges:
...nursing a prisoner, and abortion...I don’t know if I’m...allowed to decline that, I’m not sure. But I haven’t experienced it here yet.
Sub-theme 2: Role models: the good, the bad and the ugly
Students reported various accounts of exposure to both good and bad role models. Unprofessional conduct, unfriendliness, laziness, being unapproachable, having personal discussions in front of patients and ineffective performance under pressure were some undesirable characteristics identified.
10
I really don’t like it when the nurses have discussions in front of the patients about their weekend plans, or what they did the previous night, or whatever else...it just feels very unprofessional to me... (Student 4, translated)
Students perceived agency staff as more likely to display these characteristics.
...they (agency staff) do their own thing, and work on their own. They, like, don’t care... (Student 9, translated)
Many positive role models were identified, including nursing unit managers, mentors, bridging students and clinical training staff. Students indicated that these individuals had a motivating impact on them. Qualities valued included professionalism, willingness to help and teach students, caring attitudes, ability to handle pressure and showing respect for people, including students.
Student 1 particularly appreciated the safe learning environment created by a theatre nurse practitioner:
...she knows how to reduce fear in a student. And she stands up for her students
a lot in theatre.
Sub-theme 3: A cut above
All the students indicated feeling proud and privileged to study at the selected private hospital. Apart from indicating how much they enjoyed working in the wards, they also reported getting excellent clinical exposure, especially when compared with fellow students from smaller hospitals in the group. Students further commented on the high standards maintained at this specific hospital, and the positive impact thereof on their learning experiences:
Once you’ve done your training...you can go anywhere outside in the world and nurse, and you will be a good nurse, because they really teach...students the proper thing; and they’re strict, but...you come out with lots of knowledge and you’ll be confident and you’ll be able to work anywhere... (Student 1, translated)
DISCUSSION
To our knowledge, this is one of the first qualitative educational research studies to be conducted in the private health care sector in South Africa. The information
crystallised from the data clearly demonstrates how student nurses’ interpretations and perceptions of their clinical learning environment within the context of this study may influence their learning experiences in both positive and negative ways.
The theme on preconceptions demonstrated how personal contact with nurses or nursing care during their earlier years, as well as nursing stereotypes, influenced students’ perceptions of nursing even before entering the profession. This theme also highlighted the positive outcomes of building on valuable and accurate preconceptions, as demonstrated by the students’ increased perceptions of nursing as a caring profession and of themselves as being more caring since exposure to patient contact. However, when students’ expectations were not met in reality, they experienced disappointment and discomfort which may directly influence the quality of their clinical learning experiences (Gallagher, 2007). Billett (2006, p. 39) maintains that, despite curriculum intentions, people in the workplace are responsible for regulating learners’ access to “activities and interactions and provide the support that regulates learners’ progression”. The theme on workplace dynamics revealed how social processes, interpersonal relationships, hierarchical structures, and staff shortages may work together in the clinical arena by sending subtle messages to students about their role and place in the hierarchy, as well as the behaviours required to fit in. Student responses further indicated a task orientation in the wards, where students were expected to adopt worker roles and adhere to a hierarchical system.
It is in the workplace context that discrepancies often emerge between the intended and experienced curriculum. Teaching-learning dynamics operating in the selected context suggested many discrepancies between what was taught in class and what students actually experienced in practice. This sends conflicting messages to students, which may cause frustration and anxiety.
Student responses on feedback demonstrated ineffective feedback practices, including a lack of continuous, verbal feedback and reflection. The power games played by some nursing staff with regard to student feedback reports can seriously hamper students’ motivation to learn. A formal investigation is required into the
12
feedback practices in the specific context to identify the extent of practice reform required.
A positive finding in the context of this study was that a practical assessment system drives learning through the message emitted to students that assessment opens doors by expanding their scope of practice. This theme demonstrated how the curriculum could be managed to benefit student learning and promote internal motivation to learn.
None of the students indicated a compromise of personal values. However, some uncertainty emerged as to how they would handle such a confrontation when faced with it. Despite some tensions and discrepancies, student responses indicated an overall positive learning experience, influenced by many positive role models, good learning support from clinical educators and diverse learning opportunities. These positive aspects should be strengthened and used as motivators for student learning. This includes an increased focus on student mentoring, and even greater involvement of clinical training staff in student supervision, feedback, and reflective activities.
Student responses also indicated that maintaining high quality standards in the working environment and sensitizing students to the importance thereof, may be helpful in providing safe boundaries within which students can develop into competent, knowledgeable practitioners who will be able to function effectively in any context.
As nurse educators, we aim to develop self-directed, professional practitioners with the ability to think critically and perform nursing care in a scientific manner. However, unintended learning in the clinical context may instead promote conforming behaviour, compliance, and rote practice. A shift in focus is required towards a student-centred learning approach that will provide the type of ward atmosphere and degree of psychological support conducive to student engagement and active participation in learning. In order to achieve this, the following recommendations are proposed:
• Adopting a constructivist approach to learning with the aim of using students’ unique and diverse prior learning experiences as a starting point (Gallagher,
2007). This might include action-learning activities at the start of the course where students are facilitated in examining their preconceptions and clarifying their values.
• In-service training can be useful to focus the attention of ward staff, mentors, and clinical supervisors on students’ learning needs, as well as on the importance of feedback and reflection.
• Clinical educators can promote optimal participation of ward staff by involving them in the planning of learning opportunities for students.
• In order to limit theory-practice discrepancies, it may be worthwhile to investigate ways to align classroom teaching with the current realities of staff shortages and time constraints experienced in the clinical arena. • Minimal protected learning time should be negotiated with hospital
management to allow time for procedure assessments outside of their placement wards, without students having to face conflict with ward staff. • Problem-based learning activities, learning portfolios and reflective journals
could further be helpful in stimulating the development of critical thinking skills and reflective qualities in nursing students.
CONCLUSION
The challenge remains to best prepare students for the complexities and dynamics of the workplace learning environment, while at the same time modifying this environment to effectively meet students’ learning needs. It is therefore essential that we as educators make the effort to listen to and learn from our students, as it is only through knowing what our students truly need that we will be able to implement positive change and facilitate powerful learning experiences (Ramsden, 2003).
LIMITATIONS
The main limitation of this study lies in its methodology. Only one group of students from one particular learning context was investigated. Further studies of nursing students’ perceptions of their clinical learning environment from other hospital
14
contexts, including the public sector, are needed to assess the generalisability of the findings from this small-scale study.
Acknowledgements
The authors wish to acknowledge the following people and institutions:
• The students who participated in this study, for their valuable contributions
• Ms M Van Heusden, for assistance with translating the consent forms and interview questionnaire
• Ms M Dednam, for transcribing the interviews
• The management of Panorama Medi-Clinic, for permission to conduct the study at this hospital
Funding: None
Conflicting interests declared: None
REFERENCES
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Denzin, N.K., Lincoln, Y.S. (Ed). 2000. Handbook of Qualitative Research. 2nd Ed. California: Sage Publications.
Dunn, S.V., Hansford, B. 1997. Undergraduate Nursing Students’ Perceptions of their Clinical Learning Environment. Journal of Advanced Nursing 25(6), 1299-1306.
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Lee, C.H., French, P. 1997. Ward Learning in Hong Kong. Journal of Advanced Nursing 26, 455-462.
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Table 1: Themes and sub-themes derived from analysis of interview data
THEMES SUB-THEMES
Theme 1: Preconceptions
“Fantasy meets reality”
Sub-theme 1: Personal contact with nursing
“The root of it all”
Sub-theme 2: Nursing stereotypes
“In the eye of the beholder”
Theme 2: Workplace dynamics
“The work of learning”
Sub-theme 1: Staff attitudes
“Sink or swim”
Sub-theme 2: Staff shortages
“Helping hands”
Sub-theme 3: Hierarchy
“In the line of duty”
Theme 3: Teaching-learning dynamics
“The learning game”
Sub-theme 1: Theory-practice discrepancies
“When in Rome...”
Sub-theme 2: Ineffective feedback
“Feedback, backwards”
Sub-theme 3: Assessment drives learning
“Assessment opens doors”
Theme 4: Values
“The values of the Profession”
Sub-theme 1: Value clarification
“To do, or not to do, that is the question...”
Sub-theme 2: Role modelling
“Role models: the good, the bad, and the ugly”
Sub-theme 3: Nursing standards
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If excerpts from other copyrighted works are included, the Author(s) must obtain written permission from the copyright owners and credit the source(s) in the article. Elsevier has preprinted forms for use by Authors in these cases: contact Elsevier's Rights Department, Philadelphia, PA, USA: phone (+1) 215 239 3804, fax (+1) 215 239 3805, e-mail healthpermissions@elsevier.com. Requests may also be completed online via the Elsevier homepage (http://www.elsevier.com/locate/permissions ).
Presentation of Papers
experience of previously published colleagues where possible. It is not possible to change the content of accepted papers during production.
Do not use 'he', 'his' etc where the sex of the person is unknown, say 'the nurse' etc. Avoid inelegant alternatives such as 'he/she'. Nurses should not be automatically designated as 'she', and doctors as 'he'. In terms of style, try to avoid artificially objective language such as 'the author thought that' or 'the researcher' where this person is yourself. 'I' or 'we' are acceptable when related to matters concerning the author(s) themselves or their opinions.
Title page
•The title page should be provided as a separate file.
•Your title page should give the title in capital letters, below which should be the
authors' names (as they appear) in lower-case letters.
•For each author you should give one first name as well as the family name and any initials
•Authors' addresses should be limited to the minimum information needed to ensure accurate postal delivery; these details should be on the title page below the authors' names and appointments
•Authors should also provide a daytime contact telephone number, fax number and e-mail address.
Keywords
Include three or four keywords. The purpose of these is to increase the likely accessibility of your paper to potential readers searching the literature. Therefore, ensure keywords are descriptive of the study. Refer to a recognised thesaurus of keywords (e.g. MEDLINE, CINAHL) wherever possible.
Abstract/Summary
An abstract of your paper, a maximum of 200 words summarising the content, should
follow the title page. Headings
The content of your paper should determine the headings you use. If yours is a quantitative research paper the headings should follow the usual layout, such as:
Introduction, Background/Literature, Methods, Data/Results, Discussion,
Conclusions. If your paper takes another form, theoretical or qualitative for example,
you should use the appropriate headings, but do bear in mind that headings should facilitate reading and understanding. You should use only two kinds of headings, major headings should be indicated by underlined capital letters in the centre of the page whereas minor headings should be underlined, have lower-case letters (beginning with a capital) and begin at the left hand margin.
Tables
Each table needs a short descriptive title above it, and a clear legend or key and, if necessary, suitably identified footnotes below. When drawing up the tables take care to include all the units of measurement. Make sure that each table is cited in the text.
Illustrations
A detailed guide on electronic artwork is available on our website:
http://www.elsevier.com/authors
If, together with your accepted article, you submit usable colour figures then Elsevier will ensure, at no additional charge, that these figures will appear in colour on the web (e.g., ScienceDirect and other sites) regardless of whether or not these illustrations are reproduced in colour in the printed version. For colour reproduction in print, you will receive information regarding the costs from Elsevier after receipt of your accepted article.
Borrowed material should be acknowledged in the captions in this style: Reproduced by kind permission of ... (publishers) ... from ... (reference).
Reference Style
The accuracy of the references you provide is your responsibility.
•In the text references should state the author's surname and the year of publication (Smith, 1989). If there are two authors you should give both surnames (Smith & Black, 1989). When a source has more than two authors, give the name of the first author followed by 'et al.'.
•Where a quotation is used within your paper the author, date and page number should be given, e.g. 'Pain probably disables more people than any single disease entity.' (McCaffery 1979, p.1)
•A list of all references in your manuscript should be typed in alphabetical order. Each reference to a paper needs to include the authors' surnames and initials, year of publication, full title of the paper, full name of the journal, volume number, issue
number and first and last page numbers.Do not add unnecessary punctuation.
For example:
Aggleton, P., Allen, M., Montgomery, S., 1987. Developing a system for the continuous assessment of practical nursing skills. Nurse Education Today 7 (4), 158-164
References to Books should be given in a slightly different form, as in these
examples:
Houle, Co., 1972. The Design of Education. Jossey-Bass, San Francisco. Quinn, S., 1982. Nursing education in the countries of the Common Market. In: Henderson, M.S. (Ed.), Nursing Education. Churchill Livingstone, Edinburgh, pp. 125-140
The digital object identifier (DOI) may be used to cite and link to electronic documents. The DOI consists of a unique alpha-numeric character string which is assigned to a document by the publisher upon the initial electronic publication. The correct format for citing as DOI is shown as follows (example taken from a document in the journal Physics Letters B):
doi: 10.1016/j.physletb.2003.10.071
When you use the DOI to create URL hyperlinks to documents on the web, they are guaranteed never to change.
Citing and listing of Web references: As a minimum, the full URL should be given. Any further information, if known (Author names, dates, reference to a source publication, etc.), should also be given. Web references can be listed separately (e.g., after the reference list) under a different heading if desired, or can be included in the reference list.
Proofs
When your manuscript is received by the Publisher it is considered to be in its final form. Proofs are not to be regarded as "drafts". One set of page proofs in PDF format will be sent by e-mail to the corresponding Author, to be checked for
typesetting/editing. No changes in, or additions to, the accepted (and subsequently edited) manuscript will be allowed at this stage. Proofreading is solely your
responsibility. A form with queries from the copyeditor may accompany your proofs. Please answer all queries and make any corrections or additions required.
your article corrected and published as quickly and accurately as possible. In order to do this we need your help. When you receive the (PDF) proof of your article for correction, it is important to ensure that all of your corrections are sent back to us in one communication. Subsequent corrections will not be possible, so please ensure your first sending is complete. Note that this does not mean you have any less time to make your corrections, just that only one set of corrections will be accepted. Should you choose to mail your corrections, please return them to: Log-in Department, Elsevier, Stover Court, Bampfylde Street, Exeter, Devon EX1 2AH, UK.
Offprints
The corresponding author, at no cost, will be provided with a PDF file of the article via e-mail. The PDF file is a watermarked version of the published article and includes a cover sheet with the journal cover image and a disclaimer outlining the terms and conditions of use. Additional paper offprints can be ordered by the authors. An order form with prices will be sent to the corresponding author. For further information please consult http://www.elsevier.com/authors
Funding body agreements and policies
Elsevier has established agreements and developed policies to allow authors whose articles appear in journals published by Elsevier, to comply with potential manuscript archiving requirements as specified as conditions of their grant awards. To learn more about existing agreements and policies please visit
http://www.elsevier.com/fundingbodies
Enquiries
Authors can keep a track on the progress of their accepted article, and set up e-mail alerts informing them of changes to their manuscript's status, by using logging on to:http://authors.elsevier.com/TrackPaper.html. For privacy, information on each article is password-protected. The author should key in the "Our Reference" code (which is in the letter of acknowledgement sent by the publisher on receipt of the accepted article) and the name of the corresponding author. In case of problems or questions, authors may contact the Author Service Department, E-mail: authorsupport@elsevier.com
CHECKLIST
Before submitting your paper. please check that: •All files are uploaded.
•The reference list is complete and in correct style
•Written permission from original publishers and authors to reproduce any borrowed material has been obtained.
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